Decision Date: 08/28/95 Archive Date:
08/28/95
DOCKET NO. 93-28 407 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Buffalo,
New York
THE ISSUE
Entitlement to an increased evaluation for post-traumatic
stress disorder (PTSD), currently evaluated as 10 percent
disabling.
REPRESENTATION
Appellant represented by: New York Division of Veterans'
Affairs
ATTORNEY FOR THE BOARD
A. A. Booher, Counsel
INTRODUCTION
The veteran had active service from December 1966 to June
1968.
This appeal to the Board of Veterans' Appeals (the Board) is
from a rating action by the Department of Veterans Affairs
(VA) Regional Office (RO) in Buffalo, New York, in May 1993.
REMAND
The veteran's primary argument is that his disabilities, of
which PTSD is one, seriously hinder his social life and
significantly hamper his ability to work. In this context,
it is important to note that in addition to PTSD, the
veteran also has service connection for corneal leukoma,
light perception only, right eye, residuals of fragment
wound, rated as 30 percent disabling; corneal scarring and
narrowing of palpebral fissure, right eye, rated as 10
percent disabling; scar, left hand, with retained foreign
body, residuals of shell fragment wound, rated 10 percent
disabling; and scar, face, without disfigurement, rated zero
percent disabling. He is also in receipt of special monthly
compensation on account of loss of use of one eye having
only light perception. Accordingly, given the nature of his
disabilities, and as part of the Board's consideration of
his claim for increased compensation for PTSD, it is clear
that the issue of a total rating based on individual
unemployability due to service-connected disabilities is
also pertinent to this claim. The veteran is currently
unemployed.
The veteran's outpatient records through part of 1992 are in
the file, showing that various testing procedures had
demonstrated anxiety and an underlying personality disorder
as well as his PTSD. The veteran also has a history of
alcohol abuse, and has participated in some therapy
programs. Any VA Vocational, Rehabilitation and Education
(VR&E) or Counseling files are not in the claims folder.
The limited VA psychiatric evaluation and social and
industrial survey conducted in September 1992 noted that the
veteran had a history of having lost his home the prior year
because he was unable to pay the mortgage after he started
to abuse alcohol, which resulted in his loss of his job, a
divorce and multiple charges of driving while under the
influence (DWI) of alcohol. The psychiatric examiner noted
that the veteran had described himself as having started to
drink more and more heavily when things became stressful,
and eventually he was charged with DWI's and had an
altercation with his boss and quit. He said that when he
realized he had a drinking problem, he had gone to the VA
facility at Bath, NY, for rehabilitation and had started
going to AA. Recent records from neither are in the file.
The examiner noted that the veteran said that he become
depressed and anxious and had started to drink more and more
to control his anxiety and depression. There was some
evidence of consciousness and anxiety about his other
service-connected disabilities particularly relating to his
eye and face. He also reported that he was continuously
aggressive and worried about everything.
Based on the evidence of record, the Board finds that
additional development is appropriate. The case is REMANDED
for the following actions:
1. The RO should obtain complete, up-to-date VA outpatient
and evaluative records from Bath, New York, including from
ongoing therapy, as well VA Vocational Rehabilitation and
Education (VR&E) and Counseling files, if any, and all of
this should be attached to the claims folder.
2. The RO should make arrangements for a VA examination of
the veteran by a psychiatrist and a psychologist who have
not treated or examined him previously to determine the
nature and extent of his PTSD. The veteran should be
requested to provide information concerning his recent
social and work experience including the reported
altercation with his boss, and any subsequent attempts to
find a job, part-time work, being turned down for jobs due
to disability, etc. All necessary tests and studies should
be accomplished, and all clinical manifestations should be
reported in detail. The examiners should complete a
multiaxial diagnosis, identifying all current psychiatric
disorders, and offer an opinion of the extent to which the
veteran's service-connected psychiatric disorder interferes
with his ability to establish and maintain relationships as
well as the reduction in initiative, efficiency, flexibility
and reliability levels due to his service-connected
psychiatric disorder. In this regard, the terms mild,
definite, considerable, severe, and total are the preferred
descriptive adjectives. A complete rationale for any
opinion expressed must be provided. The examiners should
indicate the veteran's overall psychological, social, and
occupational functioning using the Global Assessment of
Functioning scale provided in the Diagnostic and Statistical
Manual of Mental Disorders, correlating these findings with
prior clinical evidence of record The examiners should also
provide a clear indication as to the nature of all
appropriate diagnoses, the relationship and relative impact
of any given psychiatric disorder on his other service-
connected problems, and vice-versa, and a delineation of the
nature and current alcohol abuse, and its relationship to
the veteran's psychiatric problems, if any. The claims
folder should be made available to the examiners prior to
and during the examination of the veteran.
3. After completion of the requested development, the case
should be reviewed by the RO with regard to all pertinent
regulations in association with assessments on both a
schedular and extraschedular basis, to include entitlement
to a total rating based on individual unemployability due to
service-connected disabilities. If the decision is adverse,
a Supplemental Statement of the Case should be prepared, and
the veteran and his representative should be afforded the
opportunity to respond.
The case should then be returned to the Board for further
appellate review. The veteran need do nothing further until
so notified. No inference regarding the ultimate
determination of the case should be drawn from this remand.
GARY L. GICK
Member, Board of Veterans' Appeals
The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740,
___ (1994), permits a proceeding instituted before the Board
to be assigned to an individual member of the Board for a
determination. This proceeding has been assigned to an
individual member of the Board.
Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the
Board of Veterans' Appeals is appealable to the United
States Court of Veterans Appeals. This action has been
taken in accordance with the Veterans' Benefits Improvements
Act of 1994, Pub. L. No. 103-446, § 303, 108 Stat. 4645, ___
(1994), and is in the nature of a preliminary order and does
not constitute a decision of the Board on the merits of your
appeal. 38 C.F.R. § 20.1100(b) (1994).
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